Provider Demographics
NPI:1255690368
Name:BANDALO CHIROPRACTIC INC
Entity Type:Organization
Organization Name:BANDALO CHIROPRACTIC INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MIRO
Authorized Official - Middle Name:
Authorized Official - Last Name:BANDALO
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:404-683-4007
Mailing Address - Street 1:1428 PHILLIPS LN
Mailing Address - Street 2:SUITE 300
Mailing Address - City:SAN LUIS OBISPO
Mailing Address - State:CA
Mailing Address - Zip Code:93401-2537
Mailing Address - Country:US
Mailing Address - Phone:805-843-8688
Mailing Address - Fax:805-543-8732
Practice Address - Street 1:1428 PHILLIPS LN
Practice Address - Street 2:SUITE 300
Practice Address - City:SAN LUIS OBISPO
Practice Address - State:CA
Practice Address - Zip Code:93401-2537
Practice Address - Country:US
Practice Address - Phone:805-843-8688
Practice Address - Fax:805-543-8732
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-05-09
Last Update Date:2012-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CADC32149111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty